1. Compliance Responsibility
and Healthcare Quality: What
Does Your Board Need to
Know?
HCCA Quality of Care Compliance
Conference
Philadelphia, PA
October 13, 2009

2. What are the goals of the organizations quality improvement
program? What metrics and benchmarks are used to measure
progress towards each of these performance goals? How is each
goal specifically linked to management accountability?
Our goals for our patients are to:
• Decrease Mortality
• Decrease Morbidity
• Increase Patient Satisfaction
• Improve Patient Safety
• We utilize the University Healthcare Consortium for
benchmarks in mortality, morbidity and safety. Our
patient satisfaction information utilizes the Press Ganey
organization, and the Pickar survey.
• Each Clinical Chair will be asked to report their
departments progress on these goals to the Board at
least annually.

3. How does the organization measure and improve the
quality of patient care? Who are the key management
and clinical leaders responsible for these quality and
safety programs?
We measure and improve the quality of patient care with the following
metrics:
• UHC Reports:
– Quality and Safety Management Report (QSMR)
– Hospital Quality Measures Report (HQMR)
– Clinical Outcomes Report
– Key Indicator Report
– Quality and Accountability Report
• Patient and Referring Physician Satisfaction Surveys
• Hospital Quality Matrix
• Hospital Incentive Program
• Each of the 19 clinical departments are responsible for ensuring the
quality and safety of their departments.

4. How are the organizations quality assessment and improvement
processes integrated into overall corporate policies and operations? Are
clinical quality standards supported by operational policies? How does
management implement and enforce these policies? What internal
controls exist to monitor and report on quality metrics?
• Our faculty adheres to the policy and procedures
of the health care entities in which they practice.
• The Compliance Committee of the School of
Medicine enforces the compliance of the
practices of the school.
• The Credentialing Committee credentials all
providers.
• The Medical Management Committee has been
charged by the Board to develop, implement,
and review all the quality and safety activities of
the organization.

5. Does the board have a formal orientation and
continuing education process that helps members
appreciate external quality and patient safety
requirements? Does the board include members with
expertise in patient safety and quality improvement
issues?
• The Medical Director meets with each of the Department
Chairs, or their designee to share and review the
departments quality and safety data and develop
improvement plans when necessary.
• The Board includes members with expertise in patient
quality and safety.

6. Physician Education and Training
 Partnership between Medical Education, IUSOM, & Quality
 Residents, Faculty, New medical staff, & Medical students.
Orientations for all new interns, 3rd year med students, new
faculty on staff.
 Ongoing training with quality and safety lunches,
intersessions for med students, orientation for new faculty
mid-year.
 Core curriculum
 Quality, Safety, Medical Equipment, EHR, Regulatory
Compliance, Infection Control, Medication Safety, etc.
 Designed for orientation & on-going information sharing

7. What information is essential to the board’s ability to understand and
evaluate the organization’s quality assessment and performance
improvement programs? Once these performance metrics and
benchmarks are established, how frequently does the board receive
reports about the quality improvement efforts?
• The Board requires each of the Clinical Departments to
report at least annually to report on the following:
• Mortality
• Morbidity
• Satisfaction
• Safety
• CMS Physician Voluntary Reporting Program (PQRI)
• EHR implementation
• Communication with referring physicians and patients

8. How does the quality assessment and improvement
processes coordinated with its corporate compliance
program? How are quality of care and patient safety
issues addressed in the organization’s risk assessment
and corrective action plans?
• The physician faculty are integral to promoting corporate
compliance, as well as to risk management and
organizational reputation. All employees and faculty are
encouraged to use the confidential hotline numbers to
report compliance issues anonymously. The use of the
hotline is not limited to compliance, and can be used for
quality and safety concerns as well.
• We collaborate with each of our hospital partners in their
risk assessment and corrective action programs

9. What processes are in place to promote the reporting
of quality concerns and medical errors and to protect
those who ask questions and report problems? What
guidelines exist for reporting quality and patient safety
concerns to the board?
• We encourage all employees and faculty to utilize the
confidential compliance hotlines to report any issue. All
quality and safety issues are investigated by the Medical
Director, and are reviewed by the Medical Management
Committee, which reports to the Board. All such reports
are handled in a confidential manner.

10. Are human and other resources adequate to support
patient safety and clinical quality? How are proposed
changes in resource allocation evaluated from the
perspective of clinical quality and patient care? Are
systems in place to provide adequate resources to
account for differences in patient acuity and care
needs?
• Resources are assessed at least on an
annual basis. Our Board has recently
allocated additional resources for quality
and safety.
• We utilize the UHC case mix index to
benchmark the acuity of our patients.

11. Does the competency assessment and training,
credentialing, and peer review processes adequately
recognize the necessary focus on clinical quality and
patient safety issues?
• We review malpractice complaints, the
National Practitioner Databank, patient
satisfaction, credentialing and physician
specific complaints. The Credentialing
Committee and the Medical Management
Committee review and act on this
information and report to the Board.

12. How are “adverse patient events” and other medical
errors identified, analyzed, reported, and incorporated
into performance improvement activities? How do
management and the board address quality
deficiencies without unnecessarily increasing the
organization’s liability exposure?
• We are linked to the Risk Management
departments of each of our affiliated hospitals.
We also assist with the following:
• State Department of Health Reportable Events
• JCAHO Sentinal Events
• Internal investigations and Reviews of adverse
events

13. Questions?
Lisa Hancock, RN, CHP, CHC, MHA
Compliance Officer
Sutter Medical Foundation
2800 L Street, 7th floor
Sacramento, CA 95816
ph. 916.454.6917
hancocl@sutterhealth.org